The use of sub-arachnoid block in a restless eclamptic is not very common. Studies have demonstrated some benefits of sub-arachnoid block over general anaesthesia in stable eclamptic but its role in the management of unstable eclampsia has not been established. Reported below is an eclamptic parturient who was restless despite magnesium sulphate regimen and possesed features suggestive of difficult airway who had uneventful subarachnoid- block for caesarean section.

Introduction

Spinal anaesthesia in stable eclampsia is no longer new [1-6].
Eclampsia is said to be unstable if there are associated complications such
as thrombocytopenia, raised intra cranial pressure, uncontrollable convulsions,
restlessness, fetal distress, unconsciousness (GCS < 9), respiratory failure
and haemorrhage [4,5]. Studies have
demonstrated some benefits of sub-arachnoid block over general anaesthesia
in stable eclamptic [1,2,4-6].
The use of sub-arachnoid block in a restless eclamptic has not been documented.
James et al administered spinal anaesthesia to unstable eclamptic patients
in 1912 without recording any mortality having ealier on had serial mortalities
with general anaesthesia in patients with eclampsia [1].
Paramore actually administered spinal anaesthesia to an unstable eclamptic
in 1930 with the aim of using it to abort convulsions [2].
Faced with anaesthetic dilemma, Nafiu et al offered spinal anaesthesia to
an unstable eclamptic patient with mild thrombocytopenia and an impossible
airway without history of spinal haematoma [4]. We present
anaesthetic management in an unstable eclamptic parturient who was restless
despite magnesium sulphate regimen and possessed features suggestive of difficult
airway.

Patient and observation

Mrs.G. B was a 23 year old Gravida 1 para 0 trader who resided
at Okela street Ado-Ekiti, Nigeria. She was transferred from a
comprehensive health centre to the Ekiti State University Teaching
Hospital in
Ado-Ekiti,
Ekiti State, Southwest Nigeria, on the 3rd of April, 2014 at
11.00hrs. She presented on account of convulsion of several episodes
at the referring Comprehensive Health Centre before presentation
at the hospital.
Convulsions were said to be tonic-clonic in nature with associated
drooling of saliva. There was no fecal or urinary incontinence.
No history of post
ictal sleep. She had regular menstrual cycles of 5 days in a 30
days cycle prior to conception. The first day of her last menstrual
period could not
be ascertained. She had all her antenatal follow up at the referring
comprehensive health centre. However, the result of the first ultrasound
scanning done
was not available for perusal. Since admission, she had diazepam
but subsequently had another episode of convulsion. She was later
given magnesium sulphate
which abated further convulsion. There was no previous history
of convulsion before the index pregnancy. No prior history of head
trauma. No family or
previous history of epilepsy. Nil previous anaesthetic exposure
nor blood transfusion. No history of drug allergy. Nil intercurrent
medical ailment
predating pregnancy. On examination she was drowsy and restless.
Glasglow coma scale could not be assessed. She was not pale and
anicteric, mildly dehydrated.
Her pulse rate was 120 bpm, Blood pressure was 160/100 mmHg, respiratory
rate was 38 cycles per minute. Her lung field was clear clinically.
Abdominal examination reveals a uniformly enlarged uterus with
symphysio-fundal height
of 32 cm compactible with a gestational age of 34 weeks. Longitudinal
lie ,cephalic presenting fetus. She was having two uterine contractions
in 10
minutes each lasting for 30 seconds. Fetal heart sound was 140
beats/minute.She had normal vulva, a posteriorly located closed
cervix measuring 2cm long
and 80% effaced.There was no vaginal bleeding.

After about 4 hours of stabilisation, she was later scheduled for emergency caesarean
section. She was held in place on the operating table because she was restless.
Monitors were attached. Intravenous access was achieved with 18-G cannula. Owing
to the possibility of difficult airway, plan was to administered sub-arachnoid
block. Intravenous midazolam 4mg in aliquots of 2 mg was given to manage her
restlessness. Thereafter she was calm and had a preload of 750 mls of normal
saline. The patient received ranitidine 50mg and 10mg metoclopramide intravenously
30 minutes prior to surgery. Following the application of routine monitoring,
non-invasive monitoring was commenced and documented including non-invasive blood
pressure (NIBP), oxygen saturation (SPO2), pulse (PR), systolic blood
pressure (SBP), diastolic blood pressure (DBP). Induction of spinal anaesthesia
was achieved with patient held by two assistants in sitting position. Her legs
were completely kept straight on the operating table, unlike the conventional
method where legs were hanging from the edge of the operating table with the
support of a stool under her feet. She was assisted in bending her neck forward
and arching out her back maximally. Under aseptic condition, the spinal needle
was introduced into the subarachnoid space. After withdrawing the stylet from
the spinal needle, appearance of the free flow of cerebrospinal fluid in the
hub of the needle indicated a successful placement. She received 2.2ml of 0.5%
hyperbaric bupivacaine plus 10 mg pethidine over 15s intrathecally in the L3-4
intervertebral space with a 26 G Quincke's spinal needle. The patient was immediately
put in supine position with a 15° left lateral tilt using wedge under the right
hip. Sensory bock height was assessed using loss of sensation to gentle pin prick
test. A sensory block height of T6 was the minimum desired level of block for
the commencement of the caesarean section. The following parameters: pulse rate,
systolic blood pressure, diastolic blood pressure, and oxygen saturation were
recorded. Following the delivery of the first twin, the mother was inadvertently
given 10 units of oxytocin intravenously before the delivery of the second twin,
then she had infusion of 40 units of oxytocin in 500 mls normal saline to run
for 4 hours. One minute Apgar scores for first and second twins were 6 and 7
respectively. Postoperatively, she was transferred to the ward where she
became conscious within 24 hours following anaesthesia. She was discharged home
alongside
her two neonates having spent seven days in the ward.

Discussion

The patient presented in this case report was having persistent restlessness
and drowsiness despite management with magnesium sulphate for 4
hours prior to spinal anaesthesia. It has also been documented
by Paramore et al that
spinal anaesthesia could actually be used to prevent further restlessness
and convulsions in eclampsia [2]. General anaesthesia
would have been a technique of choice in this patient with unstable
eclampsia, but the presence of features suggestive of difficult
airway did not favour
it. In the face of difficult intubation, the attendant hypoxia
(desaturation), aspiration pneumonitis, aggravated laryngeal oedema,
pressor response to
laryngoscopic and intubation can be exaggerated in this eclamptic
parturient [5,6]. Although Mallampati
assessment could not be carried out, the patient has short neck,
large and swollen
tongue and more swollen face due to significant tissue edema. It
is recommended that regional anaesthesia as the best possible choice
in most cases of anticipated
difficult airway. Spinal anaesthesia supports haemodynamic stability,
avoids multiple drug interractions (especially, unwarranted potentiatoion
of non-depolarizing
muscle relaxant by magnesium sulphate [7]). The temporary
difficulty in positioning her for induction of spinal anaesthesia
was alleviated with the help of two assistants who positioned her
on the operating table.
Because the patient was drowsy, two assistants put her in sitting
position on the operating table. We also did not have difficult
or failed spinal
anaesthesia. This finding was in support of findings of Singh et
al and Basu et al who had no difficult or failed spinal anaesthesia
amongst the
eclamptic patients who had spinal aneasthesia [5,6].
The procedure which was performed by a consultant anaesthetist
was not associated with any form of difficulty in passing spinal
needle nor spinal haematoma.
The platelet count in our patient was normal. Yuen et al observed
spinal haematoma in a patient with a twin pregnancy required a
Caesarean section
for severe pre-eclampsia [8]. She presented with platelet
count of 71 x 109 cells/L. She had spinal haematoma following
epidural anaesthesia. Razzaque et al. demonstrated safety of spinal
anaesthesia in stable eclampsia and concluded that spinal anaesthesia
is safer than
general anaesthesia for Lower Segment Caesarean Section in eclamptics
[9].

We used 26 G spinal needle for this present patient. Even in the face of thrombocytopenia,
Nafiu et al did not record any spinal haematoma after a successful spinal anaesthesia
in an unstable eclamptic patient with thrombocytopenia [4].
For most centres, the lowest acceptable platelet count for subarachnoid block
is still a subject of controversy. However some authors peg the minimal allowable
count at 100 x 109cells/L [4-6]. Basu et al reported
that 11 out of 30 neonates in eclamptics with general anesthesia group had resuscitatation
with Ambubag-mask ventilation compared to 2 in spinal anaesthesia [6].
Dasqupta et al compared neonatal outcome in women with severe pre-eclampsia undergoing
Caesarean section under spinal or general anesthesia and found that neonates
in mothers with spinal anaesthesia had better Apgar scores [10].
This was in accordance with our study where the two neonates had 1 min Apgar
score of 6 and 7. Basu et al found that parturients with general anaesthesia
was associated with prolonged hospital stay. This corroborated our finding where
the patient was discharged after 7 days of admission. The case presented was
one of the few selected cases of unstable eclamptic parturients that can benefit
from spinal anaesthesia for caesearen section. Although spinal anaesthesia has
been confirmed to be useful in stable eclamptcs, its use in unstable eclamptics
should be individualized. Apart from patients with thrombocytopenia and raised
intra cranial pressure, spinal anaesthesia may be favoured in some selected cases.

Conclusion

The case reported highlights the use of an uneventful spinal anaesthesia
for caesarean section in eclamptic with unaborted restlessness and drowsiness.
The case presented was one of the few selected cases of unstable eclamptic
parturients that can benefit from spinal anaesthesia for caesearen section.

Competing interests

The authors declare no competing interests.

Authors’ contributions

JM Afolayan was involved in the collection of the data and the literature research, and he also wrote the manuscript. BA Olofinbiyi helped with the patient management, revision of the manuscript and OM Ipinnimo helped with patient management and obstetric part of the manuscript writing. All authors read and approved the final manuscript.

Acknowledgments

We wish to thank the senior registrar anaesthetist, nurse anaesthetist.
Peri-operative nurses, obstetricians and everybody who participated in the
report.